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Gamma probe-assisted excision of an ectopic parathyroid adenoma located within the thymus: case report and review of the literature.

Daliakopoulos SI, Chatzoulis G, Lampridis S, Pantelidou V, Zografos O, Ioannidis K, Sapranidis M, Ploumis A - J Cardiothorac Surg (2014)

Bottom Line: PTH detection and frozen biopsy were performed during surgery and confirmed the successful excision of the adenoma, while mild hypocalcaemia was noticed postoperatively.We conclude that accurate preoperative and intraoperative localization of an ectopic parathyroid adenoma is crucial to successful surgery.The use of at least two diagnostic modalities before surgical excision minimizes the risk of re-operation for recurrent hyperparathyroidism, while the intraoperative use of gamma probe offers a significant advantage over conventional techniques by reducing surgical time, morbidity and/or complications associated with surgical exploration.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Thoracic Surgery, 424 General Military Hospital, Eukarpia Ring Road, Thessaloniki Gr 564 29, Greece. savvas.lampridis@gmail.com.

ABSTRACT
Primary hyperparathyroidism due to parathyroid adenomas may be associated with ectopic parathyroid gland localization in 20-25% of the patients. We report herein the excision of an ectopic parathyroid adenoma which was detected in the thymus gland by gamma probe intraoperatively. A 38-year-old patient presented to our clinic with a history of bilateral nephrolithiasis, chronic hypercalcaemia, and PTH elevation. A combination of Technetium-99 m sestamibi scintigraphy and Computed Tomography scan of the chest and neck revealed an ectopic parathyroid adenoma of 8.5 mm in its greatest dimension. The patient underwent sternotomy and the adenoma was found within the right lobe of the thymus gland with the intraoperative use of gamma probe. PTH detection and frozen biopsy were performed during surgery and confirmed the successful excision of the adenoma, while mild hypocalcaemia was noticed postoperatively. We conclude that accurate preoperative and intraoperative localization of an ectopic parathyroid adenoma is crucial to successful surgery. The use of at least two diagnostic modalities before surgical excision minimizes the risk of re-operation for recurrent hyperparathyroidism, while the intraoperative use of gamma probe offers a significant advantage over conventional techniques by reducing surgical time, morbidity and/or complications associated with surgical exploration.

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Thyroid-parathyroid sestamibi scan image of an ectopic parathyroid adenoma. A thyroid-parathyroid sestamibi scan image showing an ectopic parathyroid adenoma below the lower pole of the thyroid gland, in a possible intrathoracic position.
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Figure 1: Thyroid-parathyroid sestamibi scan image of an ectopic parathyroid adenoma. A thyroid-parathyroid sestamibi scan image showing an ectopic parathyroid adenoma below the lower pole of the thyroid gland, in a possible intrathoracic position.

Mentions: Four months before surgery an abdomen CT and a pyelogram showed a urolith of 1.5 cm maximum diameter in the left renal pelvis and 2–3 smaller uroliths in the lower pole of the left kidney with mild hydronephrosis. At the same time, a thyroid-parathyroid sestamibi scan revealed an ectopic parathyroid adenoma below the lower pole of the thyroid, probably inside the thorax (Figure 1). In a thyroid ultrasound, a nodule 8.7 × 5.7 cm with internal vascularization was seen. Three months preoperatively the patient underwent an extracorporeal lithotripsy. At that time, a chest CT revealed a cervical intrathoracic nodule close to the thymus gland, about 1 cm in diameter, and multiple lymph nodes in the posterior cervical triangle bilaterally, while no swollen lymph nodes were recorded in the mediastinum (Figure 2). Laboratory findings one month before surgery were: serum calcium (Ca): 12.1 mg/dl (normal range: 8.5-10.2), 24-hour urine Ca: 316 mg/dl (normal range: 25–300), serum sodium (Na): 141 mmol/l (normal range: 135–145), serum urea: 25 mg/dl (normal range: 20–45), serum creatinine: 0.86 mg/dl (normal range: 0.72-1.25), parathormone (PTH): 164 pg/ml (normal range: 8–51). Preoperative laboratory findings were: hematocrit: 47.6% (normal range: 41–50), white cell count: 9.3 × 103/μl (normal range: 4.2-11 × 103), serum Ca: 12.3 mg/dl, phosphorus (P): 2.1 mg/dl (normal range: 2.3-4.7), alkaline phosphatase (ALP): 130 U/L (normal range: 40–150), serum urea: 30 mg/dl, serum creatinine: 0.78 mg/dl, triiodothyronine (T3) total: 0.6 ng/ml (normal range: 0.6-2), thyroxine (T4) total: 3.03 μg/dl (normal range: 3.2-12), thyroid stimulating hormone (TSH): 1.08 μUI/ml (normal range: 0.27-4.70). PTH just before surgery was 171.6 pg/ml (baseline). Preoperatively, a 99mTc sestamibi scan with 740 mBq (20 mCi) was performed and planar imaging of the neck and chest was taken on a dual head gamma camera after a delay of 20 minutes and repeated after 2 hours. This test demonstrated a mild uptake of the sestamibi in the neck region with concomitant increased uptake in the upper anterior mediastinum in the delayed phase.


Gamma probe-assisted excision of an ectopic parathyroid adenoma located within the thymus: case report and review of the literature.

Daliakopoulos SI, Chatzoulis G, Lampridis S, Pantelidou V, Zografos O, Ioannidis K, Sapranidis M, Ploumis A - J Cardiothorac Surg (2014)

Thyroid-parathyroid sestamibi scan image of an ectopic parathyroid adenoma. A thyroid-parathyroid sestamibi scan image showing an ectopic parathyroid adenoma below the lower pole of the thyroid gland, in a possible intrathoracic position.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4230425&req=5

Figure 1: Thyroid-parathyroid sestamibi scan image of an ectopic parathyroid adenoma. A thyroid-parathyroid sestamibi scan image showing an ectopic parathyroid adenoma below the lower pole of the thyroid gland, in a possible intrathoracic position.
Mentions: Four months before surgery an abdomen CT and a pyelogram showed a urolith of 1.5 cm maximum diameter in the left renal pelvis and 2–3 smaller uroliths in the lower pole of the left kidney with mild hydronephrosis. At the same time, a thyroid-parathyroid sestamibi scan revealed an ectopic parathyroid adenoma below the lower pole of the thyroid, probably inside the thorax (Figure 1). In a thyroid ultrasound, a nodule 8.7 × 5.7 cm with internal vascularization was seen. Three months preoperatively the patient underwent an extracorporeal lithotripsy. At that time, a chest CT revealed a cervical intrathoracic nodule close to the thymus gland, about 1 cm in diameter, and multiple lymph nodes in the posterior cervical triangle bilaterally, while no swollen lymph nodes were recorded in the mediastinum (Figure 2). Laboratory findings one month before surgery were: serum calcium (Ca): 12.1 mg/dl (normal range: 8.5-10.2), 24-hour urine Ca: 316 mg/dl (normal range: 25–300), serum sodium (Na): 141 mmol/l (normal range: 135–145), serum urea: 25 mg/dl (normal range: 20–45), serum creatinine: 0.86 mg/dl (normal range: 0.72-1.25), parathormone (PTH): 164 pg/ml (normal range: 8–51). Preoperative laboratory findings were: hematocrit: 47.6% (normal range: 41–50), white cell count: 9.3 × 103/μl (normal range: 4.2-11 × 103), serum Ca: 12.3 mg/dl, phosphorus (P): 2.1 mg/dl (normal range: 2.3-4.7), alkaline phosphatase (ALP): 130 U/L (normal range: 40–150), serum urea: 30 mg/dl, serum creatinine: 0.78 mg/dl, triiodothyronine (T3) total: 0.6 ng/ml (normal range: 0.6-2), thyroxine (T4) total: 3.03 μg/dl (normal range: 3.2-12), thyroid stimulating hormone (TSH): 1.08 μUI/ml (normal range: 0.27-4.70). PTH just before surgery was 171.6 pg/ml (baseline). Preoperatively, a 99mTc sestamibi scan with 740 mBq (20 mCi) was performed and planar imaging of the neck and chest was taken on a dual head gamma camera after a delay of 20 minutes and repeated after 2 hours. This test demonstrated a mild uptake of the sestamibi in the neck region with concomitant increased uptake in the upper anterior mediastinum in the delayed phase.

Bottom Line: PTH detection and frozen biopsy were performed during surgery and confirmed the successful excision of the adenoma, while mild hypocalcaemia was noticed postoperatively.We conclude that accurate preoperative and intraoperative localization of an ectopic parathyroid adenoma is crucial to successful surgery.The use of at least two diagnostic modalities before surgical excision minimizes the risk of re-operation for recurrent hyperparathyroidism, while the intraoperative use of gamma probe offers a significant advantage over conventional techniques by reducing surgical time, morbidity and/or complications associated with surgical exploration.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Thoracic Surgery, 424 General Military Hospital, Eukarpia Ring Road, Thessaloniki Gr 564 29, Greece. savvas.lampridis@gmail.com.

ABSTRACT
Primary hyperparathyroidism due to parathyroid adenomas may be associated with ectopic parathyroid gland localization in 20-25% of the patients. We report herein the excision of an ectopic parathyroid adenoma which was detected in the thymus gland by gamma probe intraoperatively. A 38-year-old patient presented to our clinic with a history of bilateral nephrolithiasis, chronic hypercalcaemia, and PTH elevation. A combination of Technetium-99 m sestamibi scintigraphy and Computed Tomography scan of the chest and neck revealed an ectopic parathyroid adenoma of 8.5 mm in its greatest dimension. The patient underwent sternotomy and the adenoma was found within the right lobe of the thymus gland with the intraoperative use of gamma probe. PTH detection and frozen biopsy were performed during surgery and confirmed the successful excision of the adenoma, while mild hypocalcaemia was noticed postoperatively. We conclude that accurate preoperative and intraoperative localization of an ectopic parathyroid adenoma is crucial to successful surgery. The use of at least two diagnostic modalities before surgical excision minimizes the risk of re-operation for recurrent hyperparathyroidism, while the intraoperative use of gamma probe offers a significant advantage over conventional techniques by reducing surgical time, morbidity and/or complications associated with surgical exploration.

Show MeSH
Related in: MedlinePlus